Provider Demographics
NPI:1477500049
Name:RICKER, MARI A (MD)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:A
Last Name:RICKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:ANOUSKA
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 245052
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5052
Mailing Address - Country:US
Mailing Address - Phone:520-626-5914
Mailing Address - Fax:520-626-1640
Practice Address - Street 1:707 N ALVERNON WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1827
Practice Address - Country:US
Practice Address - Phone:520-694-8888
Practice Address - Fax:520-694-1640
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023146Medicaid
ORP00604911OtherRR MEDICARE
AZ49518OtherMEDICAL LICENSE
OR023146Medicaid